Chapter 29 Psychiatric Nursing Sexual Assault

When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur during the long-term phase of reorganization, which symptoms should be included? Select all that apply. a. Development of fears and phobias c. Feelings of numbness d. Flashbacks, dreams

ANS: A, C, D These reactions are common to the long-term phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase. Syncopal episodes would not be expected.

A rape victim says to the nurse, "I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?" Which communication by the nurse is most therapeutic? a. Support the victim to separate issues of vulnerability from blame.

ANS: A Although the victim may have made choices that made her vulnerable, she is not to blame for the rape. Correcting this distortion in thinking allows the victim to begin to restore a sense of control. This is a positive response to victimization. The distracters do not permit the victim to begin to restore a sense of control or offer use of non-therapeutic communication techniques. In this interaction, the victim needs to talk about feelings rather than prevention.

A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on." Select the nurse's most appropriate response. a. "Are you thinking of harming yourself?"

ANS: A The patient's words suggest hopelessness. Whenever hopelessness is present, so is suicide risk. The nurse should directly address the possibility of suicidal ideation with the patient. The other options attempt to offer reassurance before making an assessment.

A nurse works a rape telephone hotline. Communication with potential victims should focus on: a. explaining immediate steps victims should take.

ANS: A The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Counseling is not the focus until immediate problems are resolved. The victim remains anonymous. The other distracters are inappropriate or incorrect because counselors are trained to be empathetic rather than sympathetic.

A victim of a sexual assault who sits in the emergency department is rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which stage of rape-trauma syndrome? a. The acute phase reaction

ANS: A The victim's response is typical of the acute phase and shows cognitive, affective, and behavioral disruptions. This response is immediate and does not include a display of behaviors suggestive of the long-term (reorganization) phase, anger, or a delayed reaction.

Select all that apply. An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? a. Camera b. Body map c. DNA swabs

ANS: A, B, C Body maps, DNA swabs, and photographs are used to collect and preserve body fluids and other forensic evidence.

Select all that apply. A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? a. Allow the patient to talk at a comfortable pace. b. Place the patient in a private room with a caregiver. c. Pose questions in nonjudgmental, empathetic ways.

ANS: A, B, C Neutral, nonjudgmental care and emotional support are critical to crisis management for the rape victim. The rape victim should have privacy but not be left alone. The rape victim's anxiety may escalate when touched by a stranger, even when the stranger is a nurse. Some rape victims prefer not to have family involved. The patient's privacy may be compromised by family presence.

Select all that apply. Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? a. Coping mechanisms the patient is using d. Signs and symptoms of emotional and physical trauma e. Adequacy and availability of the patient's support system

ANS: A, D, E The nurse assesses the victim's level of anxiety, coping mechanisms, available support systems, signs and symptoms of emotional trauma, and signs and symptoms of physical trauma. The history of STDs or previous sexual experiences has little relevance.

The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, "If I avoid strangers or situations where I am alone outside at night, I'll be safe from sexual attacks." Choose the nurse's best response. d. "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."

ANS: D Females know their offenders in almost 70% of all violent crimes committed against them, including rape. The nurse should share this information along with encouraging discussion of safety measures. The distracters fail to provide adequate information or encourage discussion.

A victim of a sexual assault comes to the hospital for treatment but abruptly decides to decline treatment and leaves the facility. While respecting the person's rights, the nurse should: b. provide written information about physical and emotional reactions the person may experience.

ANS: B All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to later. Patients may not be kept against their will or coerced into treatment. This constitutes false imprisonment.

n unconscious teenager is treated in the emergency department. The teenager's friends suspect a rape occurred at a party. Priority action by the nurse should focus on: b. maintaining physiologic stability.

ANS: B Because the patient is unconscious, the risk for airway obstruction is present. The nurse's priority will focus on maintaining physiologic stability. The distracters are of lower priority than preserving physiological functioning.

A nurse interviews a 17-year-old male victim of sexual assault. The victim is reluctant to talk about the experience. Which comment should the nurse offer to this victim? b. "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person."

ANS: B Few rape survivors seek help, even with serious injury; so, it is important for the nurse to help the victim discuss the experience. The correct response therapeutically gives information to this victim. A male rape victim is more likely to experience physical trauma and to have been victimized by several assailants. Males experience the same devastation, physical injury, and emotional consequences as females. Although they may cover their responses, they too benefit from care and treatment. "Why" questions represent probing, which is a non-therapeutic communication technique. The victim may or may not have friends who have had this experience, but it's important to talk about his feelings rather than theirs.

Which situation describes consensual sex rather than rape? b. A woman's lover pleads with her to have oral sex. She gives in but later regrets the decision.

ANS: B Only the key describes a scenario in which the sexual contact is consensual. Consensual sex is not considered rape if the participants are of legal age.

An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important? b. Consent signed by the patient

ANS: B Patients have the right to refuse legal and medical examination. Consent forms are required to proceed with these steps.

After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that a patient is in the acute phase of the rape-trauma syndrome? b. Confusion and disbelief

ANS: B Reactions of the acute phase of the rape-trauma syndrome are shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity. Flashbacks, dreams, fears, and phobias are seen in the long-term reorganization phase of the rape-trauma syndrome. Decreased motor activity by itself is not indicative of any particular phase.

A nurse in the emergency department assesses an unresponsive victim of rape. The victim's friend reports, "That guy gave her salty water before he raped her." Which question is most important for the nurse to ask of the victim's friend? b. "Has the victim consumed any alcohol?"

ANS: B Salty water is a slang/street name for GHB (γ-hydroxy-butyric acid), a Schedule III central nervous system depressant associated with rape. Use of alcohol would produce an increased risk for respiratory depression. GHB has a duration of 1-12 hours, but the duration is less important that the potential for respiratory depression. Seeking evidence is less important than the victim's physiologic stability.

Select all that apply. A rape victim tells the emergency nurse, "I feel so dirty. Help me take a shower before I get examined." The nurse should: b. explain that bathing destroys evidence. d. offer the victim a shower after evidence is collected.

ANS: B, D As uncomfortable as the victim may be, she should not bathe until the examination is completed. Collection of evidence is critical for prosecution of the attacker. Showering after the examination will provide comfort to the victim. The distracters will result in destruction of evidence or are untrue.

A rape victim visited a rape crisis counselor weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful? c. "I'm sleeping better although I still have an occasional nightmare."

ANS: C Rape-trauma syndrome is a variant of posttraumatic stress disorder. The absence of signs and symptoms of posttraumatic stress disorder suggest that the long-term reorganization phase was successfully completed. The victim's sleep has stabilized; occasional nightmares occur, even in reorganization. The distracters suggest somatic symptoms, appetite disturbances, and self-blame, all of which are indicators that the process is ongoing.

A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic response. d. "You feel as though this would not have happened if you had not been alone."

ANS: D A reflective communication technique is most helpful. Looking at one's role in the event serves to explain events that the victim would otherwise find incomprehensible. The distracters discount the victim's perceived role and interfere with further discussion.

A woman was found confused and disoriented after being abducted and raped at gunpoint by an unknown assailant. The emergency department nurse makes these observations about the woman: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the woman's level of anxiety? d. Severe

ANS: D Acute anxiety results from the personal threat to the victim's safety and security. In this case, the patient's symptoms of rapid, dissociated speech, inability to concentrate, and indecisiveness indicate severe anxiety. Weak is not a level of anxiety. Mild and moderate levels of anxiety would allow the patient to function at a higher level.

The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency department. Select the most appropriate outcome to achieve before discharging the patient. d. The patient agrees to a follow-up appointment with a rape victim advocate.

ANS: D Agreeing to keep a follow-up appointment is a realistic short-term outcome. The victim is in the acute phase; the distracters are unlikely to be achieved during the limited time the victim is in an emergency department.

Before a victim of sexual assault is discharged from the emergency department, the nurse should: d. provide referral information verbally and in writing.

ANS: D Immediately after the assault, rape victims are often disorganized and unable to think well or remember instructions. Written information acknowledges this fact and provides a solution. The distracters violate the patient's right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective.

A nurse cares for a rape victim who was given a drink that contained flunitrazepam (Rohypnol) by an assailant. Which intervention has priority? Monitoring for: d. respiratory depression.

ANS: D Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma.

A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I can't talk about it. Nothing happened. I have to forget." What is the patient's present coping strategy? d. Denial

ANS: D The patient's statements reflect use of denial, an ego defense mechanism. This mechanism may be used unconsciously to protect the person from the emotionally overwhelming reality of the rape. The patient's statements do not reflect somatization, compensation, or projection.